|Year : 2021 | Volume
| Issue : 1 | Page : 6-11
Knowledge, perceptions, and barriers to personal protective equipment usage with suggested remedial measures among health-care workers during COVID-19 pandemic
Suraj Kapoor1, Prem Vardhan1, Vivek Anand2, S Vijay Bhaskar1, Arun Kumar Yadav1, Saurabh Mahajan1, Mandeep Kaur1, Surinder Kumar3
1 Department of Community Medicine, AFMC, Pune, Maharashtra, India
2 Department of Community Medicine, Clinical Tutor, AFMC, Pune, Maharashtra, India
3 DADH Amritsar, Punjab, India
|Date of Submission||24-May-2021|
|Date of Decision||24-May-2021|
|Date of Acceptance||27-May-2021|
|Date of Web Publication||24-Nov-2021|
Department of Community Medicine, AFMC, Pune, Maharashtra.
Source of Support: None, Conflict of Interest: None
Introduction: Personal protective equipment (PPE) is the most powerful method to protect health-care professionals from contact with infectious agent. This study was conducted with an aim to assess knowledge, perceptions, and barriers to PPE usage among health-care workers (HCWs) with assessment of suggested remedial measures against COVID-19. Materials and Methods: A cross-sectional descriptive study was conducted among health-care professionals involved in COVID care across the country. Results: A total of 167 study participants were included in the study with a mean age of 31 years with standard deviation of 4.4. A total of 123 (74%) of the participants had a knowledge score of 5 or more out of 11 (above average), while 44 (26%) had score <5 suggesting poor knowledge. On inquiring about various barriers/challenges faced while using PPEs, visual problem due to fogging of goggles was found to be most common among 158 (94%) of the study participants. On assessing various remedial measures suggested by study participants to improve vision due to fogging, 54% of participants suggested application of thin layer of clear shower gel or any high-viscosity clear liquid on inner side of protective goggles before donning, while about 20% of study participants suggested application of micropore/elastoplast over the nose bridge to seal the mask properly. To overcome communication/hearing problem, about 32% of the study participants suggested use of microphone along with a portable speaker to amplify the voice. Conclusion: To promote good infection prevention and control strategies, it is necessary to impart training in the field of appropriate use of PPEs. This study may serve as a guide to health administrators as well as other HCWs in adopting ways and means to ameliorate the problems encountered in the use of PPE kits.
Keywords: COVID-19, knowledge, attitudes and practices, personal protective equipment
|How to cite this article:|
Kapoor S, Vardhan P, Anand V, Bhaskar S V, Yadav AK, Mahajan S, Kaur M, Kumar S. Knowledge, perceptions, and barriers to personal protective equipment usage with suggested remedial measures among health-care workers during COVID-19 pandemic. D Y Patil J Health Sci 2021;9:6-11
|How to cite this URL:|
Kapoor S, Vardhan P, Anand V, Bhaskar S V, Yadav AK, Mahajan S, Kaur M, Kumar S. Knowledge, perceptions, and barriers to personal protective equipment usage with suggested remedial measures among health-care workers during COVID-19 pandemic. D Y Patil J Health Sci [serial online] 2021 [cited 2022 Nov 27];9:6-11. Available from: http://www.dypatiljhs.com/text.asp?2021/9/1/6/331110
| Introduction|| |
COVID-19 infection caused by SARS CoV-2 virus is a respiratory tract illness which can spread from human to human by contact and droplet transmission. It was first identified in Wuhan, China, in December 2019 and later spread to rest of the world. Health-care workers (HCWs) are at an increased risk of infection because of their close and prolonged contact with COVID-19-positive patients. Personal protective equipment (PPE) is the most powerful method to protect health-care professionals from contact with infectious agents. The use of PPE for HCWs has evolved from the isolation precautions first implemented years ago for patients with communicable diseases, particularly respiratory group of infections such as tuberculosis, smallpox, and diphtheria. PPE includes gowns, surgical caps, masks, respirators, coveralls, gloves, goggles, and shoe covers. Specific challenges in a hospital environment are patient care, handling of infectious samples for diagnostics, and the work with dead bodies. The WHO guidelines suggest an effective infection prevention and control (IPC) strategy with special emphasis on the appropriate use of PPEs for tackling COVID-19. HCW managing patients should be professionally trained in the correct use and removal of PPEs with the importance of hand hygiene.
The most effective and simple way to prevent infection in the hospital is to follow standard precautions, which are a set of recommendations designed to prevent or minimize exposure to infectious agents by hospital staff, patients, and their visitors. It is important to carefully select the appropriate PPE to protect the skin, eyes, face, nose, mouth, hands, feet, head, and other parts of the body, to provide protection, and act as an effective barrier between the HCW and the contaminated materials such as blood, body fluids, respiratory secretions, and aerosols. PPEs can prevent infection if used properly as per the recommended donning and doffing guidelines and inappropriate use of PPEs may provide a false sense of security against COVID-19.
Globally, the users have often found wearing the PPE uncomfortable while working, more so in the summer season, when facilities for controlling the environmental temperature like centralized air conditioners are unavailable or are shut down for fear of spreading the infection. In addition to reduced tactile sensitivity and impaired visibility due to the deposition of water vapors on the eye goggles with their use, users have also found verbal communication difficult while wearing the PPE. Although the literature is available globally highlighting the problems associated with PPE usage, Indian studies are limited. Hence, this study was conducted with an aim to assess knowledge, perceptions, and barriers to PPE usage among HCWs with assessment of suggested remedial measures against COVID 19.
| Materials and Methods|| |
Study design, population, and sampling methods
A descriptive cross-sectional study was conducted from August to December 2020 among 167 HCWs comprising of doctors, nurses, and paramedical staff involved in COVID care across the country. A web-based self-administered questionnaire was designed using “Google Forms” to assess knowledge, perceptions, and barriers to PPE usage. The questionnaire was formulated using reference material on the appropriate use of PPE in COVID19 developed by the WHO, Centers for Disease Control and Prevention, and Ministry of Health and Family Welfare. The questionnaire was distributed among the study participants in the form of “Google Forms” via various media platforms such as WhatsApp, Gmail, and Facebook. The sampling technique followed was the snowball sampling method. Informed consent was obtained from all the study participants. The study was given institutional ethical clearance and data were analyzed in aggregated and anonymized form.
The questionnaire included demographic information such as age, gender, and, academic profile [Table 1] followed by questions to assess knowledge of the study participants about PPE usage [Table 2]. The second part of the questionnaire comprised practice/attitude and barrier among HCWs about PPE usage [Table 3] and remedial measures [Table 4].
|Table 1: Demographic and occupational characteristics of study participants (n=167)|
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|Table 2: Knowledge about appropriate use of personal protective equipment (n=167)|
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|Table 3: Practices/perceptions/attitudes and barriers in personal protective equipment usage (n=167)|
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|Table 4: Common remedial measures employed by study participants in response to barriers of personal protective equipment usage (n=167)|
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Knowledge was assessed by giving a score of 1 to each correct answer and 0 to the wrong answer. The scale measured knowledge from maximum 11 to minimum 0. Score ≥5 was taken as average, whereas score <5 taken as poor knowledge.
The data from the Google Forms were downloaded in MS Excel. The data were cleaned and coded. The data were analyzed using IBM Statistical Package for Social Sciences (SPSS) version 23.0 (Department of Community Medicine, AFMC, Pune, Maharashtra, India). The categorical variables were summarized using frequency, proportions, and ratios, while Chi-square test was used to determine the association between study variables. P < 0.05 was considered statistically significant.
| Results|| |
The demographic and occupational characteristics of study participants are mentioned in [Table 1]. A total of 167 study participants were included in the study with a mean age of 31 years with standard deviation of 4.4 and majority (73.7%) were male. More than 50% were doctors and the rest equally comprised nurses and paramedical including laboratory staffs. Nearly half of the study participants were doing clinical care of COVID patients, while the other half were involved in various IPC measures such as disinfection, biomedical waste (BMW), and laboratory work.
A total of 123 (74%) of the participants had a knowledge score of 5 or more out of 11 (above average), while 44 (26%) had score < 5 suggesting poor knowledge [Table 2]. On assessing practices, attitude, and perception about PPE usage, a total of 121 (74%) were trained about donning and doffing practices with a significant difference among the specialties, paramedical staff being less trained (P < 0.05). About 68% of participants were confident of donning/doffing practices as per the guidelines with paramedical staff being less confident. More than 75% of the study participants suggested that PPE provides nearly 100% protection.
On inquiring about various barriers/challenges faced while using PPEs, visual problem due to fogging of goggles was found to be most common among 158 (94%) of the study participants. Difficulty in communication with patients and co-workers while using PPE was observed by 75% of the study participants. A total of 89 (95%) doctors, 19 (52%) nursing, and 18 (50%) paramedical staff reported difficulty in communicating with patients, with doctors facing more difficulty in communication using PPE (P < 0.05); similarly, 90 (96%) doctors, 20 (60%) nursing, and 18 (50%) paramedic staff found difficulty in communicating with co-workers while using PPE, with doctors facing more problem than their counterparts (P < 0.05). Other barriers/challenges faced by the study participants while using PPE are given in [Table 3].
On assessing various remedial measures suggested by the study participants to improve vision due to fogging, 54% of participants suggested application of a thin layer of clear shower gel or any high-viscosity clear liquid on the inner side of protective goggles before donning, while about 20% of the study participants suggested application of micropore/elastoplast over the nose bridge to seal the mask properly. To overcome communication/hearing problems, about 32% of the study participants suggested the use of microphone along with a portable speaker to amplify the voice [Table 4].
| Discussion|| |
PPE has become an important and emotive subject during the current COVID19 pandemic. There has been a flurry of research in recent literature on coronavirus and COVID-19, centering on its epidemiology, etiopathogenesis, pathology, prevention strategy, components of prevention, and treatment. However, there are limited studies from within India that have assessed both knowledge and difficulties encountered by HCWs while using PPEs.
Numerous studies have shown that factors that contribute to noncompliance with standard precautions include lack of understanding and knowledge among HCWs on how to effectively use protective barriers, lack of time, lack of resources, and lack of proper training. Better knowledge of universal precautions among HCWs was one of the predictors of better compliance.
In our study, nearly 75% of participants had adequate knowledge about the appropriate use of PPEs and IPC measures as per the guidelines. A total of 121 (74%) were trained about donning and doffing practices; however, paramedical staff seems significantly less trained with <50% being professionally trained regarding the appropriate use of PPE. Similarly, about 68% of participants were confident of donning and doffing, while only 50% of paramedical staff were confident about the correct procedure. Active training in donning and doffing PPE has been shown to definitely boost the confidence level and reduce the risk of contamination and infection of HCWs. There should be awareness-raising mechanism, including the provision of job aids and periodic training on proper handwashing, PEP administration protocols, and safe disposal of biologically hazardous wastes including evaluation of the practices through observation by trainers to assess their level of competency against minimum acceptable standards. In addition, HCWs should be committed to safety practices. It is important to train HCWs irrespective of whether employed in clinical area or employed in various IPC measures such as disinfection and BMW. The knowledge gained by HCWs about the appropriate use of PPEs may help in reducing the spread of infection among limited manpower resource, especially in pandemic situation. In a study done in Israel during the H1N1 pandemic, it was found that PPE protection was higher among HCWs with higher self-perceived knowledge.
A recent case–control study with 241 noninfected and 13 infected staff in five Hong Kong hospitals reported that staff who wore surgical masks and N95 masks were significantly associated with noninfection, but this was not seen for paper masks.
In our study, about 61% of participants suggested adequate availability of PPEs as per the guidelines. A study done in Ethiopia suggested that HCWs working in health institutions having a continuous supply of PPE were seven times more likely to practice infection prevention compared with those who did not have continuous supply of PPE. A survey conducted across Europe and Australia has reported a shortage of PPE kits to the tune of 52% on at least one occasion and 30% incidence of reuse.
To address the shortage of supply chain, health administrators have resorted to increasing production, rationing, using the type of PPEs as per the level of protection required in particular hospital areas, do-it-yourself measures, reuse after ultraviolet C germicidal irradiation, gamma or X-ray irradiation methods of sterilization without affecting the efficacy, usage of improvised surgical gowns that can be washed, autoclaved and augmented with disposable aprons, surgical caps, shoe covers, etc.,,
Among various challenges faced while using PPEs, visual problem due to fogging was the most common problem among 158 (94%) of the participants. Fogging of the goggles impairs vision, which may lead to difficulty in performing the routine task of blood sample collection or may delay tracheal intubation. Nearly 75% of participants felt difficulty to communicate with patients and co-workers in PPE and 93% of the participants reported difficulty in hearing while using PPE. A study conducted to check the impact of PPE on communication in health-care environment found a significant difference in speech discrimination scores between normal subjects and PPE-wearing subjects. The problem of breathing difficulty/resistance was reported by 91% of the study participants. In an experimental study on effects of wearing N95 and surgical masks on subjective sensations, it was found that there was an increase in resistance to breathing and discomfort with time and increase in workload. Other challenges faced while using PPE were difficulty in examination due to decreased tactile sensation (78%) and difficulty in handling medical equipment (76%), and 130 (78%) of participants felt a significant decrease in mobility, with doctors facing more problem of mobility than their counterparts. About 68% of participants in our study felt urge to drink water while on duty in PPE. In a randomized study conducted to assess the limiting factors for wearing PPE in a health-care setting, it was found that the parameter of body fluid loss was dependent on the working temperature. Dehydration can be a significant problem when wearing PPE while working in high threat environments. HCWs must be aware of the need for proper hydration, especially if wearing PPE causes significant sweating from heat exposure. A rule of thumb is to drink 1 ml or 1oz of fluid for every 1 ml or 1 oz of body weight lost. Similarly, one must eat healthy food in part because the calories are needed to provide energy for HCWs to continue their work and because most food contains water which will help with re-hydrating the body.
Remedial measures which can be adopted to prevent fogging of the goggles are sticking a tape on the nose bridge to properly seal the mask, wiping the inner aspect of the goggles with clear high-viscosity liquid such as shower gel. Nonverbal communication such as certain gestures and body language may be picked up by patients and co-workers and use of visual aids such as sharing information pamphlets and use of whiteboard or digital tools like tablets/mobile devices can be applied in practice to prevent communication gap.
While HCWs must concentrate on their important duties and proper use of PPE for self-protection, they must also be aware of the impact of PPE on their well-being. The balance between the protection afforded by PPE and the burden of that PPE must be met with a plan to mitigate the burden. Breaks during work shifts are vital to worker health and safety. The potential physiological burden brought on by PPE use can be an unfortunate side effect; however, it can easily be remedied with a little fresh air and proper self-care. Trained observers should not only supervise the correct sequence of donning but also inquire each PPE user about the use of washroom and adequate hydration before donning. Training using various means such as audio–visuals and information, education, and communication materials such as posters displayed in donning and doffing area may be useful. HCWs should be particularly sensitized about the correct procedure of doffing, most often being neglected. Incorrect doffing of PPE can be more fatal than direct occupational exposure to the virus because medical staff may be infected while doffing PPE without realizing it, whereas direct exposure is always dealt with immediately. If during patient care any breach in PPE, the HCW must move immediately to doffing area to assess the exposure.
The results of this study may guide the development and implementation of IPC activities in health-care institutions in respect of appropriate use of PPEs in view of recent pandemic.
| Conclusion|| |
To promote good IPC strategies, it is necessary to impart training in the field of appropriate use of PPEs. Demonstrations and use of audio–visual aids about the correct sequence of donning and doffing may help in present scenarios to prevent infection among HCWs. Capacity building with planning about the requirement of adequate PPEs as per the guidelines, considering PPE requirements in COVID-19 vaccine drive as well at each hierarchical level in health-care system should be done. This study may serve as a guide to health administrators as well as other HCWs in adopting ways and means to ameliorate the problems encountered in the use of PPE kits.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]